Health Disparities, Inpatient Stays, and Emergency Room Visits Among Lesbian, Gay, and Bisexual People: Evidence From a Mental Health System

This study builds upon the broader literature on the variations in health conditions and service use among sexual minority populations in general and extends the findings within a mental health system. This study provides a unique perspective on LGB health care because PCS data are collected from EHR systems and are not self-reported. In addition, the study was guided by a well-established model on health care access and utilization (15). Therefore, its findings provide a comprehensive view on health conditions and acute service use among LGB individuals within a mental health system.

Although several studies have examined health and behavioral conditions and access to and use of health care use among sexual minority groups (21), the findings have not always been consistent because of difficulties in obtaining a representative LGB sample and appropriate control groups. Nevertheless, much of the findings support our hypothesis that there are differences in health conditions and service use between LGB individuals and heterosexuals. Some studies reported that, in general, LGB individuals compared with heterosexuals appear to have poor health/behavioral conditions (4, 12, 21). Although many studies associate poor health and use of fewer services with not having health insurance (22–27), this cannot be the case in a Medicaid-insured mental health system.

A study by Tjepkema (27) on the relationship between health care use and sexual identity among Canadians ages 18 to 59 showed that relative to heterosexuals, gay men and bisexual women were more likely to report multiple chronic conditions and physical disabilities. Bisexuals were two or more times more likely than heterosexuals to perceive their mental health as poor. These findings appear to be similar to the findings of this study: gay men, lesbians, and bisexual individuals were more likely than heterosexuals to have at least one chronic physical condition. Also, compared with heterosexuals, bisexuals and lesbians were more likely to have a physical disability. These findings suggest that even among persons with insurance and a similar propensity to access and utilize services, significant differences remain in service use and health conditions among heterosexuals and LGB individuals, with greater morbidity among the LGB population.

Although research findings on health care use among LBG individuals have varied by study location, methods, and sample, the odds of accessing or using care were either equivocal or lower in the LGB population than in the comparable population (27, 28). This analysis showed that gay men and lesbians were the least likely to either visit an ER or have a mental health–related inpatient stay. Notably, both gay men and lesbians on average tended to visit general ERs less frequently than heterosexuals. Also evident was the less frequent use of acute substance use–related services among bisexuals compared with heterosexuals. On average, bisexuals had shorter substance use–related inpatient stays and fewer substance use–related ER visits. Overall, LGB individuals appeared to have more chronic physical conditions and physical disabilities and tended to use fewer inpatient and emergency services.

The tendency for Medicaid-insured LGB individuals to use fewer acute services may be related to several factors. The stigmatization of mental illness cannot be overemphasized (29). Also, the interpersonal and structural discrimination (12) toward homosexuals, coupled with the stigmatization of homosexuality and provider attitudes toward homosexuality, indirectly serves as a barrier to care for LGB individuals (16, 30–32). This may explain the underutilization of needed health care services (12). Further, prejudice toward homosexuals may have resulted in high rates of concealment of gender and sexual identity when using health care services. In fact, about 13% (N=23,270) of the records submitted to PCS listed gender and sexual identity as unknown.The study had some limitations. First, the PCS is conducted every 2 years and uses a cross-sectional survey methodology. Although all programs licensed or funded by NYS OMH are required to complete the survey, the PCS does not capture the entire service population. Not every patient receives services during the survey week. Also, programs may not report data for all patients served during the survey week. Second, mental health providers outside the public mental health system, such as private practitioners, were not surveyed. However, the PCS is a provider-reported, not a client-reported, survey. Reporting providers collect and submit the required information from each client’s medical records. Therefore, the information collected is free of self-reporting errors. Third, services not covered under Medicaid, such as those paid out of pocket, were not accounted for in this study. Last, the study used data from Medicaid-insured individuals in the New York State mental health system and may not be generalizable to other populations.

The study provides evidence of disparities in health conditions and use of acute services among sexual-minority populations within a public mental health system. Overall, compared with matched heterosexuals, LGB individuals appeared to have more chronic physical conditions and physical disabilities and tended to use fewer inpatient and emergency services. Gay men and lesbians were the least likely to have used an inpatient or emergency room service in the past 12 months. Future work will examine use of outpatient services by LGB individuals for both general medical and behavioral conditions.

Increasing access to screening, diagnostic, and preventive services among members of sexual minority groups should be a key component of federal, state, and local health reforms. These efforts will require evidence-based strategies to effectively engage LGB individuals in treatment for both general medical and mental illness.